Background: Fournier's gangrene (FG) is a fulminant
aggressive necrotizing fascitis affecting the external genitalia, perineum and
anterior abdominal wall with significant mortality rate. The aim of the present
study was to describe the associated risk factors, presentation, diagnosis, management
and outcome of this condition in Benghazi, Libya.

Patients& Methods: Over a period of twenty years (from January
1997 to October 2016) a series of 54 consecutive patients who were admitted to
Urology Department, Hawari Center for Urology and Otolaryngology, Benghazi-Libya
were evaluated retrospectively to assess the risk factors, etiology, management
and outcome of this fatal disease.

Results: It was found that 37 (68.5%) of patients were
diabetics and 24 patients (44.4%) had perianal abscess as predisposing factor.
Mortality rate was 14.8% (8 patients). All cases diagnosed on clinical basis.
The patients operated promptly by extensive debridement. Reconstructive surgery
done by flap or graft in plastic department to close the skin defect in most of
our patients (41 patients, 75.9%).

Conclusion:The main co-morbidity and predisposing factors of FG are diabetes
mellitus and perianal abscess respectively. Prompt aggressive debridement is
the only management to save the patient's life.

Fournier's
gangrene (described in 1764 by Baurienne and then in 1883 by Fournier) is a
necrotizing fascitis of the genitalia, perineum and even abdominal wall,
primarily affecting males and the more rarely vulva in women [1,2,3,4], causing
necrosis and subsequent gangrene of infected tissues. Culture of infected
tissue usually reveals a combination of aerobic and anaerobic organisms, which
are believed to grow in a synergistic fashion [5,6,7]. Conditions that predispose to the development of
FG include diabetes, local trauma and abscess of the genitalia and perineum [8]. A previously
well patient may become systemically unwell over a very short time course
(hours).The gangrene advances rapidly, hence its alternative name of
spontaneous fulminant gangrene of the genitalia. The diagnosis is a clinical
one, and is based on awareness of the condition and a low index of suspicion [9, 10, 11, and 12]. This condition
is a urological emergency, which need prompt extensive debridement besides
intravenous fluids and intravenous antibiotics [2,8,9,13]. A suprapubic catheter and colostomy are usually required [10,11,14]. Area of skin
loss is reconstructed by graft or flap. Mortality is in the order of 20-30% [7,8,15].

Patients &Methods

This
is a retrospective study including 54 patients who presented to urology
department over the period from January 1997 to October 2016. All patients were
diagnosed on clinical basis and admitted to the hospital immediately. They were
evaluated and supported hemodynamically by intravenous fluids, intravenous
antibiotics and underwent operation (debridement). The outcome of management is
assessed by the recovery of the patients, improvement of general condition,
closure of the skin defect either by graft, flap or secondary suture. The data
were collected from the patient's records using predesigned data flow sheet.
Descriptive statistics were performed in the study using Microsoft Excel 2013
and the results are presented as frequencies and percentage or mean.

Results

A
total of 54 patients with FG were evaluated. Their age ranges between 25 years
and 80 years with a mean age of 51.79 years (Table 1).

Clinically
all our patients presented with the classical symptoms and signs of FG
including prodromal symptoms of fever and lethargy, and intense pain and
tenderness in the genitalia that is usually associated with swelling, edema and
erythema of the overlying skin. There were also subcutaneous crepitations and
obvious gangrene of a portion of the genitalia with purulent drainage from
wounds. Fifteen (27.7%) patients presented with septic shock.

Leukocytosis
was present in 18 (33%) patients and anemia with hemoglobin less of than 10
gm/dl in 30 (55.5%) patients. Elevated serum creatinine (more than 1.5 mg/dl)
was found in 13 (24%) patients.More
than half of patients had blood sugar more than 171 mg/dl and about third of
patients had blood sugar less than 120 mg/dl.

Culture
was taken from the wounds and all yields polymicrobial nature.

All
patients underwent extensive debridement within 4 to 6 hours of admission.
Suprapubic cystostomy was inserted during the operation in 39 (72%) patients.
Repeated debridement was necessary to remove residual necrotic tissue in 25 out
of 46 (54%) patients.Colostomy was done in 12 (22%) patients who had extensive
perianal and ischiorectal involvement. Mortality rate was 14.8 % as 8 out of
the 54 patients died. All the remaining patients underwent frequent daily
dressing (at least once per day) with unprocessed honey. In five patients
(9.2%) the skin defect was small and closed with secondary suture. The
remaining 41 patients (75.9%) were transferred to plastic department where
reconstructive surgery was done by free grafting or flaps.

Discussion

Our
study showed that FG is uncommon but not rare with a reported incidence of
1/7,500, and accounting for 1%–2% of urologic hospital admissions [9,16,17].

Our
department annual activity is around 1825 admissions, so this disease comprises
about one case every 608 admissions.

In a
review of the topic Paty and coworkers calculated that approximately 500 cases
have been reported in the literature since Fournier's 1883 report, yielding a
prevalence of one case in 7500 persons. Using MEDLINE and its abstracted
journals, other researchers have reported approximately 600 cases of Fournier
gangrene in the world literature since 1996.

Although
originally described as idiopathic gangrene of the genitalia, FG has an
identifiable cause in approximately 95% of cases [18,19,20]. We identify a clear cause in 68% of patients. As about 45% ofourpatients had perianal abscesses we think that anorectal conditions is
the most important cause to develop FGand it becomes more complicated in diabetics where immunity is
compromised. The necrotizing process commonly originates from an infection in
the anorectum, the urogenital tract, or the skin of the genitalia. Causes
reported by other studies included infection in the perianal glands,
manifesting because of colorectal injury or as a complication of colorectal
malignancy, colonic diverticulitis, or appendicitis [8, 10, 11, 12, and 17]. In addition, urethral injury, iatrogenic injury secondary to urethral
stricture manipulation, or lower urinary tract infection are also reported.In
the literature co-morbid diseases that compromise the immune system have been
implicated as necessary predisposing factors for the development of FG [7,8,11,17,21]. The following are common
predisposing co-morbidities: diabetes mellitus, morbid obesity, cirrhosis,
vascular disease of the pelvis and malignancies. High-risk behaviors (e.g.,
alcoholism, intravenous drug abuser) are also implicated as promoters of FG.
Immune suppression from systemic disease [23, 24] or steroid administration
is also implicated. We found diabetes as the most prevalent co-morbidity and no
case of HIV infection reported and there is one patient among the fifty four
patients who was on long-term steroids for rheumatoid arthritis.

All
our patients presented with the classic features of necrotizing fascitis.
Thirteen out of 54 patients were shocked at presentation and most of them were
diabetics and presented late to the hospital.In some studies there were pitfalls in the clinical diagnosis of
Fournier gangrene which delay presentation [6, 25]. Some of these pitfalls
were encountered in three of our patients which led to delay of the
presentation due to incomplete examination of genitalia; because of body habits
in two patients one with morbid obesity and other with recent cerebrovascular
accident; or lack of proper communication in one psychiatric neglected patient.

We
did all the lab investigations, which are recommended in such cases to assess
the severity and co-morbidity. Some authors advise for ultrasound of the
genitalia [26] and even CT scan to see
the subcutaneous gases [27, 28] but in our hospital
besides the clinical findings we infrequently order plain X-ray to the pelvis
to detect the presence of gas and this was very sufficient (Figure 1).

Figure 1: Plain film of pelvis shows multiple
small gas bubbles (mottled gas shadows) over the involved right hemiscrotum.

Prompt
extensive debridement is the only management in addition to the supportive
measures [2,8,9,12]. As FG is considered a real surgical emergency; all cases were
extensively debrided, and most of them had suprapubic cystostomy. Although in
the literature they mentioned that urethral catheter is enough, we have seen
patients who had cystostomy doing better with fewer incidences of UTI. Given
the potential fulminant nature of this necrotizing process, repeated operative
debridement procedures were necessary to ensure complete eradication of the
infection. With the better outcome of patient who had colostomy we recommend
for this diversion to all patients who had extensive perineal and ischiorectal
involvement.

Post
operatively we used the unprocessed honey for dressing which is recommended by
some authors [17, 29] and we found it very effective for development of granulation tissue
and acts as hyperosmolar barrier against the bacteria. Hyperbaric oxygen is not
available in our hospital and with reviewing of literature the role of
hyperbaric oxygen therapy needs to be clarified with a prospective controlled
trial [30].

Most
of our cases were transferred to plastic surgery department for reconstructive
surgery although five cases were closed by secondary suture later on in urology
department without the need for grafting as the skin defect was small. The
prognosis following reconstruction is usually good.

The
mortality rate in our series is 14.8%. Most of them died due to septic shock
and one due to thrombo-embolism. The mortality in FG is usually related to the
delay in presentation, poorly controlled diabetic patients with ischemic heart
disease. Fournier disease that originates from diseases of the anorectum
produces poorer outcomes compared with other causes [20]. In the 600 cases of Fournier gangrene discovered during our MEDLINE
search dating back to 1996, 100 deaths occurred (16.5%). In the series that
included more than 20 patients, the mortality rate ranged from 4-54%, with most
studies reporting mortality rates of 20-30%.

Conclusion

Fournier's
gangrene is a life-threatening condition mostly affecting poorly controlled
diabetic middle aged men who had perianal abscess. It necessitates prompt
aggressive debridement. We found that urinary and fecal diversion is required
to hasten the healing and improve patient general condition. We also recommend the
use honey for the daily dressing. The plastic surgeon has the duty to close and
reconstruct the large skin defect over the external genitalia, perineumand abdominal wall resulted from the repeated
debridement by the urologist .

Acknowledgments

The
authors thanks Mr. AhmadBlabloo,(IT and
communicationsskills ) for hisgreat help duringthe preparation of the manuscript. Also we
thank Mr. Saleh Alwerfalli (head of department of statistics of Hawari centerof urology and ENT Benghazi-Libya, forhis help during reviewing the patient's
records.

[19]Jamieson NV, Everett WG, Bullock KN. Delayed
recognition of an intersphincteric abscess as the underlying cause of
Fournier's scrotal gangrene. Annals of the Royal College of Surgeons of
England. 1984;66(6):434.

[20]Kearney GP, Carling PC. Fournier’s gangrene: an
approach to its management. The Journal of urology. 1983;130(4):695-8.